Half of U.S. Doctors Prescribe Placebos

If you think a pill will make you feel better, it probably will. Doctors have understood this for centuries — and about half of U.S. docs still recommend medicines to patients even when there’s little or no evidence the medicine will do any good.

That finding, published this week in the British Medical Journal, comes from a survey of 679 randomly selected U.S. internists (who provide primary care) and rheumatologists (who treat arthritis).

The survey authors asked about placebos a few different ways. If a study showed that a dextrose tablet (a sugar pill) was more effective in a group of patients than no treatment at all, would doctors prescribe it? Do doctors recommend treatments “primarily because [they] believe it will enhance the patient’s expectation of getting better?”

Depending on how the question was asked, between 46% and 58% reported prescribing placebos on a regular basis. A few reported using truly inert substances, such as saltwater solutions and sugar pills. Some gave antibiotics (which kill bacteria) to patients with viral infections. Far more common were things like vitamins and over-the-counter pain medicines.

The survey was conducted by researchers at the University of Massachusetts and funded by the NIH. The finding is consistent with previous research, and not terribly surprising. But stuff like this always raises interesting ethical questions.

Health Blog Questions of the Day: Is it right for doctors to tell patients to take a medicine when the potential benefit is all in the patient’s head? If so, do doctors have a responsibility to tell the patient why they’re recommending the medicine?

Comments (5 of 25)

A recent study suggested that doctors common prescribe placebo treatments and that this behavior is considered ethically permissible. The article received a lot of press. Pity that the study is terribly flawed and misses the point.

Researchers admit that the behavior of doctors recommending treatments that weren't proven to be helpful (i.e. antibiotics for colds, which are caused by viruses and therefore can't be killed with antibiotics) was best captured by the world "placebo". Very misleading. The problem is that placebo "is a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion." Antibiotics do have therapeutic activity, just not against viruses, and can cause major side effects.

Doctors don't write prescriptions for antibiotics for the placebo effect. They prescribe it because patients demand it and to ensure that patients come back again, doctors feel pressured to comply. Research shows when patients demand advertised medications, more often then not they get exactly what they wanted. Unlike the conclusion of this study, many doctors felt ambivalent that they wrote the medication.

Saying that recommending over the counter analgesics is also a placebo is also a problem. These actually do have therapeutic effects like decreasing pain or fever. As the researchers found practically no one prescribed sugar pills.

Doctors are prescribing antibiotics and sedatives for conditions which they might not help, not because of the placebo effect, but because patients demand something be done and the offered therapies probably won't cause harm (and the doctors simply want to avoid a confrontation or discussion of why no therapy would work), doctors aren't practicing evidence-based medicine (the vast majority of sinus infections - sinusitis and bronchitis in healthy individuals does not require antibiotics and vitamin b12 injections don't help with general fatigue), or doctors just want to do something. In all three scenarios, potential harm can occur.

This is contradictory to the meaning of placebo and why the study's claim is so flawed and misleading. As the authors noted, "Few of the physicians we surveyed recommend inert placebo treatments. " i.e. pills that do nothing, like sugar pills. Why? Because unlike other cultures, like Israel where doctors about a third of the time do prescribe sugar pills, placebo treatment is not considered acceptable treatment in the United States.

Claiming that doctors commonly prescribe placebo treatments and are ethically fine with it is wrong. It is a shame that the media didn't have the level of sophistication necessary to dissect this out.

Very well, in 80% of diseases, you do not need to go to a doctor... The trouble is, the patients don't know how to recognize the other 20% when you DO...

9:44 pm October 24, 2008

MD in OR wrote :

Funny how this deliberate placebo thing irks people, we have billions spent on what amount to placebos but do not bear that label. Most alternative therapies including most herbal drugs, homeopathy, certain surgical procedures and most vitamins have either shown minimal, if any, superiority to placebo, or have not even been properly tested. the same is true for many allopathic meds, as many show minimal beneficial effects as others have noted.

I don't prescribe placebos deliberately, but I also don't argue with my patients who want to take some herbal concoction known to be fairly safe.

8:40 pm October 24, 2008

reply to sd by primary care doctor wrote :

sd - i bet you're paying a ton of meds for stuff that'd easily be substituted for drugs less than one-tenth the cost. For example: lopressor instead of coreg, glyburide instead of actos, enalapril instead of cozaar, simvastatin instead of lipitor. The list goes on and on. The reason for this is that companies like pfizer are ripping off the taxpayer, in the form of medicare part D: they advertise lipitor on TV, you go to your doctor who, rather than arguing with you, appeases you and gives you an rx for lipitor. Then you need it forever. Cha-ching! for pfizer.